Provider Demographics
NPI:1871058388
Name:WIN VISION BOUTIQUE LLC
Entity type:Organization
Organization Name:WIN VISION BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHASHATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-414-3513
Mailing Address - Street 1:22 CLIFTON COUNTRY RD STE 175
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 CLIFTON COUNTRY RD STE 175
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3864
Practice Address - Country:US
Practice Address - Phone:518-371-1881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty